Provider Demographics
NPI:1578380333
Name:PEDIATRIC NUTRITION OF SOUTHERN NEVADA
Entity type:Organization
Organization Name:PEDIATRIC NUTRITION OF SOUTHERN NEVADA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:CISEK
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:702-813-4318
Mailing Address - Street 1:401 RYLAND ST STE 200A
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1643
Mailing Address - Country:US
Mailing Address - Phone:702-813-4318
Mailing Address - Fax:
Practice Address - Street 1:3148 ECKING AVE
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89044-0291
Practice Address - Country:US
Practice Address - Phone:702-813-4318
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, PediatricGroup - Single Specialty